An Inner-City Child with Uncontrolled Asthma: Learning to Care for the Underserved Child and Lost Opportunities

34Asthma is the most common chronic lung disease of childhood, affecting approximately 7.1 million children, and those who are non-Hispanic black and Puerto Rican living in the Northeast and Midwest regions in the US in households with income below the poverty level tend to be the most affected.¹ Therefore, understanding how to treat children with severe asthma in these settings is essential to reduce the number asthma-related deaths in this population and to reduce the overall burden of asthma, it is estimated that the annual cost of managing a patient with severe asthma is double that of a patient with mild asthma.^2,3 

There are not many clinical trials looking specifically at treatment outcomes in inner-city children with asthma, thus the focus of a problem-based learning session at the ACAAI annual meeting was designed to help participants think through different sets of information relevant to the presented case study and what that information means in a clinical setting. Throughout the session several themes emerged as essential when managing these patients.

The first theme is shared-decision making, which involves finding a balance in making decisions about the child’s care and working as a team (the patient, family, and provider) to achieve the mutual goal of better-controlled asthma. The presenters mentioned that ACAAI has incorporated a shared decision-making tool that is available on their website and can help facilitate the process.

The second theme of education applied to many different levels. Primarily, patients need a basic understanding of the disease and how their self-efficacy can affect the disease. Participants also mentioned that in their experience patients often do not understand the difference between maintenance and rescue medications, which could help explain why adhering to a treatment plan might be challenging for patients. This theme also connected back to share decision-making, in that patients need to understand their treatment options in order to make informed decisions. A common technique that providers can use to see if their patient understood what they said is called “teach back,” where the provider has the patient repeat back to them the information as the patient understood the content.

Non-adherence was the final theme that emerged. There are many barriers that drive non-adherence in patients, and it is important for clinicians to build trust and open communication with their patients to find ways to overcome the barriers. Lila C. Kertz, MSN, RN, CPNP, AE-C, a pediatric nurse practitioner at the Washington University School of Medicine, stressed that there is a higher incidence of patients not picking up medication in cases of severe asthma and that open, non-judgmental conversation is essential for patients to tell providers when they have trouble taking their medications. Once patients feel comfortable in discussing the barriers to taking their medication, the clinician can work with the patient and their family to develop a plan so that they can increase their adherence. For example, a potential solution for children to increase their adherence to inhaler use is to work with the school nurse to administer the morning dose, and to provide two inhalers—one at school and one at home—so that the child is more likely to get both doses.

“The approach to treatment of severe asthma in children needs to be personalized to each patient, and the physician needs to understand the child’s and family’s worries and concerns about asthma as well as the treatment plan,” Leonard B. Bacharier, MD, FAAAAI, Professor of Pediatrics & Medicine at Washington University in St. Louis, concluded.

Citations

1. CDC/NCHS, National Health Statistics Reports. January 12, 2011:31.
2. Barnett et al. J Allergy ClinImmunol. 2011; 127:145-152 .
3. Szefler et al. Ann Allergy Asthma Immunol. 2011;107: 110-119.